Ranges from nasal obstruction Ranges from nasal obstruction till larynx and upper trachea.till larynx and upper trachea.

Obstruction of the portion of Obstruction of the portion of the airways located above the the airways located above the thoracic inlet.thoracic inlet.

StridorStridor : : ( Inspiratory stridor )( Inspiratory stridor )

- - Harsh sound produced by vibration of upper airway structureHarsh sound produced by vibration of upper airway structure

-- Indicates upper airway obstruction Indicates upper airway obstruction

HoarsenessHoarseness: : Indicates involvement of vocal cordsIndicates involvement of vocal cords

Respiratory distress / suprasternal Respiratory distress / suprasternal retractionretraction

CoughCough Signs of hypoxemiaSigns of hypoxemia

-- AnxietyAnxiety

- Restlessness- Restlessness

- Tachycardia- Tachycardia

- Pallor- Pallor

- Cyanosis: late sign- Cyanosis: late sign

InfectiousInfectious Non- InfectiousNon- Infectious

( commonest )( commonest )

Croup Croup ( Acute laryngotracheobronchitis ).( Acute laryngotracheobronchitis ). Bacterial trachitis Bacterial trachitis ( membranous croup ).( membranous croup ). Acute epiglottitis.Acute epiglottitis. Diphtheria.Diphtheria. Retropharyngeal abscess / peritonsillar. Retropharyngeal abscess / peritonsillar.

abscess.abscess.

Foreign body inhalation.Foreign body inhalation.Spasmodic laryngitisSpasmodic laryngitisCaustic burn and trauma.Caustic burn and trauma.

Term applied to group of inflammatory Term applied to group of inflammatory conditions involving larynx , trachea and conditions involving larynx , trachea and characterized by Triad : characterized by Triad :

Inspiratory stridorInspiratory stridor Brassy coughBrassy cough Hoarseness of voice +/_ resp.distressHoarseness of voice +/_ resp.distress

Usually viral in origin

- Parainfluenza virus (type 1)

- Influenza virus

- RSV , adenovirus , measles virus

It is the most common cause of Acute Airway Obstruction in children

Age group 3m-3 years (peak 2years)Affects boys more often than girlsPeak occurrence is in fall and winter

Usually h/o preceding URTI Usually h/o preceding URTI Gradual or sudden in onsetGradual or sudden in onset Triad : Triad : Inspiratory stridorInspiratory stridor Brassy coughBrassy cough Hoarseness of voice +/_ resp.distressHoarseness of voice +/_ resp.distress

It is clinically diagnosed It is clinically diagnosed

Neck x-ray and CBC all should be Neck x-ray and CBC all should be done in clinically stable pt .done in clinically stable pt .

- AP neck film : show a pencil tip or - AP neck film : show a pencil tip or steeple sign of the subglottic trachea steeple sign of the subglottic trachea

- CBC , it may helps . - CBC , it may helps .

Do not use a radiograph to Do not use a radiograph to make management decisions make management decisions in a pt. with an unstable in a pt. with an unstable airway airway

- Some children improve spontaneously - Some children improve spontaneously because of natural fluctuations in the because of natural fluctuations in the disease disease

- Mist therapy / Steam inhalation - Mist therapy / Steam inhalation

OxygenOxygen

Adequate hydrationAdequate hydration

Nebulization with Racemic epinephrineNebulization with Racemic epinephrine

Used in moderate to severe croupUsed in moderate to severe croup A child who needs admission in ICU for croup A child who needs admission in ICU for croup

management needs steroid. management needs steroid. PreparationsPreparations

Dexamethasone Nebulized Budesonide

○ Not as effective as dexamethasone○ Much more expensive than dexamethasone

Do we use steroid in mild croup Do we use steroid in mild croup ??

for Children with mild croup , dexamethasone is an effective treatment that results in

consistent and small but important clinical and economic benefits ( level Ib)

Which is more effective oral or nebulized dexamethasone for children with mild croup ?

Children with mild croup who receive oral dexamethasone Rx are less likely to seek subsequent medical care and demonstrate more rapid symptom resolution compared with children who receive nebulized dexamethasone or placebo Rx ( level Ib )

Most children with croup Most children with croup doesn't need hospitalization doesn't need hospitalization because symptoms typically because symptoms typically resolve within a few daysresolve within a few days

Signs of hypoxiaSigns of hypoxia Severe distress with exhaustionSevere distress with exhaustion Decision about ventilationDecision about ventilation

Acute epiglottitis --- Acute epiglottitis --- Hemophilus Hemophilus influenzae type Binfluenzae type B

Bacterial tracheitis --- Bacterial tracheitis --- Staph AureusStaph Aureus Cornybactrium diphtheria Cornybactrium diphtheria

It is a rapidly progreesive bacterial infection It is a rapidly progreesive bacterial infection causing acute inflammation and edema of the causing acute inflammation and edema of the epiglottis and adjacent structures : aryepiglottic epiglottis and adjacent structures : aryepiglottic folds and arytenoids folds and arytenoids

Also known as supraglottitis Also known as supraglottitis

It is life threatening condition may lead to sudden It is life threatening condition may lead to sudden and complete airway obstruction and complete airway obstruction

Age : 2-6 years ( peak at 3 year)Age : 2-6 years ( peak at 3 year)

Infant , older children and adult are Infant , older children and adult are rarely affectedrarely affected

Causative agents : Causative agents :

- - HIBHIB

- pneumococci , staphylococci, - pneumococci , staphylococci,

streptococci streptococci

Previously well child Previously well child

Sudden onset , history is short, 4-12 hours of Sudden onset , history is short, 4-12 hours of sore throat and high fever sore throat and high fever

4 “ 4 “ DD ” ” DDistressistress

DDysphagiaysphagia

DDysphonia ysphonia

DDrooling of salivarooling of saliva

may lead to may lead to ddeath if complete airway eath if complete airway obstruction obstruction

HistoryHistory PresentationPresentation Appearance of the childAppearance of the child

Pharynx examination at this stage in Pharynx examination at this stage in ER is absolutely contraindicatedER is absolutely contraindicated

Next step = admission in ICUNext step = admission in ICU Neck x-ray : Not the priorityNeck x-ray : Not the priority

Do not leave the patient unattendedDo not leave the patient unattended

Protection of the airways is the primary Protection of the airways is the primary priority priority

Quickly proceed with epiglottitis protocol Quickly proceed with epiglottitis protocol

It is better to initiate a “false” epiglottitis It is better to initiate a “false” epiglottitis drill than to miss this disease drill than to miss this disease

- Safe and supervised transfer to skilled hand- Safe and supervised transfer to skilled hand

- Inform consultant Pediatrics, ENT, ICU, Anesthesia- Inform consultant Pediatrics, ENT, ICU, Anesthesia

- Don't attempt to examine throat in ER- Don't attempt to examine throat in ER

- Keep patient as comfortable as possible- Keep patient as comfortable as possible

- Administering 100% O2- Administering 100% O2

- - Assembling at bedside CPR equipment Assembling at bedside CPR equipment including resuscitation bag and mask, including resuscitation bag and mask, intubation equipmentintubation equipment

- Taking the pt. to OR - Taking the pt. to OR

-- Attempt IV line or sampling only after intubation Attempt IV line or sampling only after intubation in OR /or Tracheostomyin OR /or Tracheostomy

* After epiglottitis protocol has been * After epiglottitis protocol has been performed and pt has secure airways you performed and pt has secure airways you can do :can do :

- blood culture : usually positive for HIB- blood culture : usually positive for HIB

- CBC : WBC may be moderately elevated- CBC : WBC may be moderately elevated

- lateral neck radiograph : shows a - lateral neck radiograph : shows a thickened epiglottis ( thumb sign ) thickened epiglottis ( thumb sign )

Diagnosis confirmed by seeing Diagnosis confirmed by seeing an edematous cherry-red an edematous cherry-red epiglottis on endoscopy epiglottis on endoscopy

Endoscopic examination should Endoscopic examination should not be performed in advance of not be performed in advance of the epiglottitis protocol the epiglottitis protocol

The main components of Rx is The main components of Rx is : :

- maintain adequate airways until inflammation - maintain adequate airways until inflammation and edema resolve often 36-72hrsand edema resolve often 36-72hrs

- Parentral Abx directed agiants HI assuming - Parentral Abx directed agiants HI assuming this is the cause : ceftriaxone or cefotaxime this is the cause : ceftriaxone or cefotaxime

if not available may use chloramphenicol if not available may use chloramphenicol

- Duration of Rx : 7-10 days - Duration of Rx : 7-10 days

ProphylaxisProphylaxis

if there is another child in the house if there is another child in the house ≤ 4 y not vaccinated to HI give ≤ 4 y not vaccinated to HI give Rifampicin to all family membersRifampicin to all family members

It is uncommon infectious cause of acute It is uncommon infectious cause of acute UAOUAO

pt may present with croup like symptoms pt may present with croup like symptoms Etiology : Staph AureusEtiology : Staph Aureus On intubation: copious thick secretion On intubation: copious thick secretion

( pus)( pus) with appropriate airway support and Abx with appropriate airway support and Abx

most pt . Improve within 5 daysmost pt . Improve within 5 days

Also known as recurrent croup Also known as recurrent croup Presentation like acute onset of croupPresentation like acute onset of croup No h/o fever or viral infectionNo h/o fever or viral infection Etiology = Allergic in natureEtiology = Allergic in nature May develop asthma or atopy later onMay develop asthma or atopy later on It typically resolves spont.It typically resolves spont. rarely associated with severe RDrarely associated with severe RD

Don’tDon’t inspect the oropharynxinspect the oropharynx send the patient to radiology for a send the patient to radiology for a

lateral neck or chest X-Raylateral neck or chest X-Ray insert an IVinsert an IV take blood gasestake blood gases

Do’sDo’s

Be calm and confidantBe calm and confidant Transfer the baby to ICU settingsTransfer the baby to ICU settings Let the baby be in mother’s lap or beside Let the baby be in mother’s lap or beside

mother to make him clam and comfortablemother to make him clam and comfortable Observe the signs of hypoxia or deteriorationObserve the signs of hypoxia or deterioration In severe cases or respiratory failureIn severe cases or respiratory failure:: secure secure

the airway ( intubation / trachesotomy)the airway ( intubation / trachesotomy)

Essentials of diagnosisEssentials of diagnosis

Acute onset of cyanosis and chokingAcute onset of cyanosis and choking*Inability to cough or vocalize (complete obstruction)*Inability to cough or vocalize (complete obstruction)

*Drooling with stridor (partial obstruction)*Drooling with stridor (partial obstruction)

Risk age groupRisk age group: 6months-4 years of age: 6months-4 years of age

Unable to speakUnable to speak Unable to breathUnable to breath Unable to coughUnable to cough

Children should be allowed to use Children should be allowed to use their own cough reflex to extrude the their own cough reflex to extrude the foreign body in case of partial foreign body in case of partial obstruction. obstruction.

If obstruction increases acute If obstruction increases acute intervention is needed.intervention is needed.

Infant <1 year of age: Infant <1 year of age: According to AAP According to AAP and AHAand AHA

** Place the infant face down over rescue arm Place the infant face down over rescue arm with head position below the trunk. Five back with head position below the trunk. Five back slaps are delivered rapidly between infant’s slaps are delivered rapidly between infant’s scapula with the heel of hand.scapula with the heel of hand.

* If obstruction persists infant should be rolled * If obstruction persists infant should be rolled over and five rapid chest compression should over and five rapid chest compression should be performed.be performed.

Repeat if not successful and call for helpRepeat if not successful and call for help

Children >1 year of ageChildren >1 year of age

Abdominal thrust ( Heimlich maneuver )Abdominal thrust ( Heimlich maneuver )

5 thrusts5 thrusts

Repeat if not successful and call for helpRepeat if not successful and call for help

If FB is directly visualized in the mouth, it If FB is directly visualized in the mouth, it can be removed by forceps.can be removed by forceps.

F.B. in trachea or lower airway: Endoscopy F.B. in trachea or lower airway: Endoscopy removalremoval

Sometimes emergency tracheostomy is Sometimes emergency tracheostomy is needed.needed.

1- www.fpnotebook.com 1- www.fpnotebook.com

2- www.emedicine.com2- www.emedicine.com

3- www.caep.com3- www.caep.com

4- www.pubmed.com4- www.pubmed.com

5- Canadian journal of emergency 5- Canadian journal of emergency medicinemedicine

6- illustrated textbook of pediatrics6- illustrated textbook of pediatrics

Croup scoring system of Westley et al1

Symptoms

Croup score

0 1 2 3 5

Stidor at rest None Audible with stethoscope

Audible without

stethoscope

– –

Retractions None Mild Moderate Severe –

Air entry Normal Decreased Severely decreased

– –

Cyanosis None With agitation

At rest – –

Level of consciousness

Normal – – – Altered